<%@ page language="java" contentType="text/html; charset=utf-8"
	pageEncoding="utf-8"%>
<%@ include file="/commons/taglibs.jsp"%>
<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<meta name="renderer" content="webkit">
<meta http-equiv="Cache-Control" content="no-siteapp" />
<title>会员信息服务</title>
<%@ include file="/commons/static.jsp"%>
<link rel="shortcut icon" href="${ctx }/home/common/img/favicon.png"
	type="image/x-icon">
</head>
</head>
<body>
		<div class="col-lg-8  col-md-12 col-sm-12 col-xs-12 col-lg-offset-2">
			<div class="widget">
				<div class="widget-header" style="text-align: center;">
				<h2>女性调查</h2>
			</div>

				<div class="widget-body" style="overflow:hidden">
					<div class="col-lg-12 col-sm-12 col-xs-12 ">
						<div class="widget">
							<section  id="sec1" name="section1" style="display: block">
							<form class="form-horizontal form-bordered" id="form" role="form" action="${ctx }/customer/saveSurveyRepor" method="post">
							<input id="customerId" value="${id }" hidden name="customerId" />
								<input id="id" value="${re.id }" hidden name="id" /> 
								<input id="content" hidden name="contentWomen" />
									<div class="bancgud row">
										<div class="formfont wjdc_top col-lg-12"><img src="${ctx }/dep/img/wenjuan.png">
											<span class="No">NO.1</span>
											<span class="inform">乳腺癌问卷量表</span>
										</div>
										
										<div>
											<h4 class="block col-lg-12">
											<div  class="">
												1.您第一次来月经的年龄是&nbsp;<span title="" class="tooltip-f">
													<select style="padding:0px 12px" id="group_1_firstMenstrualAge_select" name="group_1_firstMenstrualAge_select">
														<option value="1">12</option>
														<option value="2">13</option>
														<option value="3">14</option>
														<option value="4">15</option>
														<option value="5">16</option>
														<option value="6">17</option>
														<option value="7">18</option>
														<option value="8">19</option>
														<option value="9">20</option>
													</select>&nbsp;岁。</span>
											</div>
	                                    	</h4>
										</div>
										
										<div>
											<h4 class="block col-lg-12">2.初婚年龄 <input type="text" id="group_1_firstMarriage_text" name="group_1_firstMarriage_text" class="textbox-text validatebox-text textbox-prompt" autocomplete="off" placeholder="" style="margin-left: 0px; margin-right: 0px; padding-top: 2px; padding-bottom: 2px; width:80px;text-align:center">
												</span>&nbsp;年。</span></h4>
										</div>
										
										<div>
											<h4 class="block col-lg-12">3.您是否有过性生活？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"><input value="1" id="group_1_sexLife1_radio" name="group_1_sexLife_radio" type="radio" class="" > <span class="text">是</span></label>
													<label class="col-lg-2"> <input value="2" id="group_1_sexLife2_radio" name="group_1_sexLife_radio" type="radio" class="" > <span class="text">否</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">4.您是否生育过孩子</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"><input value="1" id="group_1_giveBirth1_radio" name="group_1_giveBirth_radio" type="radio" class="" > <span class="text">是</span></label>
													<label class="col-lg-2"> <input value="2" id="group_1_giveBirth2_radio" name="group_1_giveBirth_radio" type="radio" class="" > <span class="text">否</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">
	                                    	<div  class="">
												5.您生育第1个孩子（或第一胎）的龄是 <input type="text" id="group_1_firstGiveBirth_text" name="group_1_firstGiveBirth_text" class="textbox-text validatebox-text textbox-prompt" autocomplete="off" placeholder="" style="margin-left: 0px; margin-right: 0px; padding-top: 2px; padding-bottom: 2px; width:80px;text-align:center">
												&nbsp;岁。
											</div>
	                                    	</h4>
										</div>
										
										<div>
											<h4 class="block col-lg-12">
	                                    	<div  class="">
												6.您总共生育了
													<select style="padding:0px 12px" id="group_1_giveBirthNum_select" name="group_1_giveBirthNum_select">
														<option value="1">1</option>
														<option value="2">2</option>
														<option value="3">3</option>
														<option value="4">4</option>
														<option value="5">5</option>
													</select>&nbsp;个孩子。
											</div>
	                                    	</h4>
										</div>
										
										<div>
											<h4 class="block col-lg-12">7.怀孕期间您是否患有以下疾病 <input type="text" class="textbox-text validatebox-text textbox-prompt" autocomplete="off" placeholder="" style="margin-left: 0px; margin-right: 0px; padding-top: 2px; padding-bottom: 2px; width:80px;text-align:center">
												&nbsp;岁。</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"><input value="1" id="group_1_gestation1_radio" name="group_1_gestation_radio" type="radio" class="" > <span class="text">妊娠糖尿病</span></label>
													<label class="col-lg-2"> <input value="2" id="group_1_gestation2_radio" name="group_1_gestation_radio" type="radio" class="" > <span class="text">妊娠高血压</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">8.您累积哺乳喂养孩子的时间是 <input type="text" id="group_1_lactationTime_text" name="group_1_lactationTime_text" class="textbox-text validatebox-text textbox-prompt" autocomplete="off" placeholder="" style="margin-left: 0px; margin-right: 0px; padding-top: 2px; padding-bottom: 2px; width:80px;text-align:center">
												&nbsp;年。</h4>
										</div>
										
										<div>
											<h4 class="block col-lg-12">9.您是否服用过避孕药？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"><input value="1" id="group_1_contraceptive1_radio" name="group_1_contraceptive_radio" type="radio" class="" > <span class="text">正在使用</span></label>
													<label class="col-lg-2"> <input value="2" id="group_1_contraceptive2_radio" name="group_1_contraceptive_radio" type="radio" class="" > <span class="text">曾使用</span></label>
													<label class="col-lg-2"> <input value="3" id="group_1_contraceptive3_radio" name="group_1_contraceptive_radio" type="radio" class="" > <span class="text">从未使用</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">10.您是否已经绝经？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-4"><input value="1" id="group_1_menopause1_radio" name="group_1_menopause_radio" type="radio" class="" > <span class="text">是</span></label>
													<label class="col-lg-4"> <input value="2" id="group_1_menopause2_radio" name="group_1_menopause_radio" type="radio" class="" > <span class="text">否</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">11.您绝经时的年龄是
												<input id="group_1_menopauseAge_text" name="group_1_menopauseAge_text" type="text" class="textbox-text validatebox-text textbox-prompt" autocomplete="off" placeholder="" style="margin-left: 0px; margin-right: 0px; padding-top: 2px; padding-bottom: 2px; width:80px;text-align:center">
												&nbsp;年。</h4>
										</div>
										
										<div>
											<h4 class="block col-lg-12">12.您绝经后是否使用雌激素？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-4"><input value="1" id="group_1_estrogen1_radio" name="group_1_estrogen_radio" type="radio" class="" > <span class="text">是（继续回答下面部分）</span></label>
													<label class="col-lg-4"> <input value="2" id="group_1_estrogen2_radio" name="group_1_estrogen_radio" type="radio" class="" > <span class="text">否（结束本部分问题）</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">13.您使用了雌激素，使用了 <input id="group_1_estrogen_text" name="group_1_estrogen_text" type="text" class="textbox-text validatebox-text textbox-prompt" autocomplete="off" placeholder="" style="margin-left: 0px; margin-right: 0px; padding-top: 2px; padding-bottom: 2px; width:80px;text-align:center">
												&nbsp;年。</h4>
										</div>
										
										<div>
											<h4 class="block col-lg-12">14.您的良性乳腺疾病史情况为？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"> <input value="1" id="group_1_breastDisease1_checkbox" name="group_1_breastDisease_checkbox" type="checkbox" class="" > <span class="text">没有</span></label>
													<label class="col-lg-2"> <input value="2" id="group_1_breastDisease2_checkbox" name="group_1_breastDisease_checkbox" type="checkbox" class="" > <span class="text">乳腺增生</span></label>
													<label class="col-lg-2"> <input value="3" id="group_1_breastDisease3_checkbox" name="group_1_breastDisease_checkbox" type="checkbox" class="" > <span class="text">乳腺增炎</span></label>
													<label class="col-lg-2"> <input value="4" id="group_1_breastDisease4_checkbox" name="group_1_breastDisease_checkbox" type="checkbox" class="" > <span class="text">乳腺囊肿</span></label>
													<label class="col-lg-2"> <input value="5" id="group_1_breastDisease5_checkbox" name="group_1_breastDisease_checkbox" type="checkbox" class="" > <span class="text">乳腺纤维瘤</span></label>
													<label class="col-lg-2"> <input value="6" id="group_1_breastDisease6_checkbox" name="group_1_breastDisease_checkbox" type="checkbox" class="" > <span class="text">非典型增生</span></label>
													<label class="col-lg-2"> <input value="7" id="group_1_breastDisease7_checkbox" name="group_1_breastDisease_checkbox" type="checkbox" class="" > <span class="text">导管原位癌</span></label>
													<label class="col-lg-2"> <input value="8" id="group_1_breastDisease8_checkbox" name="group_1_breastDisease_checkbox" type="checkbox" class="" > <span class="text">小叶原位癌</span></label>
													<label class="col-lg-2"> <input value="9" id="group_1_breastDisease9_checkbox" name="group_1_breastDisease_checkbox" type="checkbox" class="" > <span class="text">其他</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">15.您是否做过乳腺活检？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"><input value="1" id="group_1_breastBiopsy1_checkbox" name="group_1_breastBiopsy_checkbox" type="radio" class="" > <span class="text">没有</span></label>
													<label class="col-lg-2"> <input value="2" id="group_1_breastBiopsy2_checkbox" name="group_1_breastBiopsy_checkbox" type="radio" class="" > <span class="text">做过</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">16.您的生殖系统疾病史情况？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"><input value="1" id="group_1_genitalDiseases1_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">没有</span></label>
													<label class="col-lg-2"> <input value="2" id="group_1_genitalDiseases2_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">子宫内膜异位症</span></label>
													<label class="col-lg-2"> <input value="3" id="group_1_genitalDiseases3_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">子宫肌瘤</span></label>
													<label class="col-lg-2"> <input value="4" id="group_1_genitalDiseases4_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">卵巢囊肿</span></label>
													<label class="col-lg-2"> <input value="5" id="group_1_genitalDiseases5_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">葡萄胎</span></label>
													<label class="col-lg-2"> <input value="6" id="group_1_genitalDiseases6_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">侵袭性葡萄胎</span></label>
													<label class="col-lg-2"> <input value="7" id="group_1_genitalDiseases7_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">宫颈癌</span></label>
													<label class="col-lg-2"> <input value="8" id="group_1_genitalDiseases8_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">子宫内膜癌</span></label>
													<label class="col-lg-2"> <input value="9" id="group_1_genitalDiseases9_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">绒毛膜癌</span></label>
													<label class="col-lg-2"> <input value="10" id="group_1_genitalDiseases10_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">卵巢癌</span></label>
													<label class="col-lg-2"> <input value="11" id="group_1_genitalDiseases11_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">输卵管癌</span></label>
													<label class="col-lg-2"> <input value="12" id="group_1_genitalDiseases12_checkbox" name="group_1_genitalDiseases_checkbox" type="checkbox" class="" > <span class="text">其他</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">17.您平常是否有以下症状<b>（可多选）</b>？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"><input value="1" id="group_1_commonSymptom1_checkbox" name="group_1_commonSymptom_checkbox" type="checkbox" class="" > <span class="text">没有</span></label>
													<label class="col-lg-2"> <input value="1" id="group_1_commonSymptom2_checkbox" name="group_1_commonSymptom_checkbox" type="checkbox" class="" > <span class="text">乳房胀痛</span></label>
													<label class="col-lg-2"> <input value="3" id="group_1_commonSymptom3_checkbox" name="group_1_commonSymptom_checkbox" type="checkbox" class="" > <span class="text">乳房肿块</span></label>
													<label class="col-lg-2"> <input value="4" id="group_1_commonSymptom4_checkbox" name="group_1_commonSymptom_checkbox" type="checkbox" class="" > <span class="text">乳头回缩</span></label>
													<label class="col-lg-2"> <input value="5" id="group_1_commonSymptom5_checkbox" name="group_1_commonSymptom_checkbox" type="checkbox" class="" > <span class="text">乳头溢液</span></label>
													<label class="col-lg-2"> <input value="6" id="group_1_commonSymptom6_checkbox" name="group_1_commonSymptom_checkbox" type="checkbox" class="" > <span class="text">乳头糜烂</span></label>
													<label class="col-lg-2"> <input value="7" id="group_1_commonSymptom7_checkbox" name="group_1_commonSymptom_checkbox" type="checkbox" class="" > <span class="text">其他</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">18.您所经历的人工流产次数为（）次？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"><input value="1" id="group_1_inducedAbortion1_radio" name="group_1_inducedAbortion_radio" type="radio" class="" > <span class="text">0</span></label>
													<label class="col-lg-2"> <input value="2" id="group_1_inducedAbortion2_radio" name="group_1_inducedAbortion_radio" type="radio" class="" > <span class="text">1</span></label>
													<label class="col-lg-2"> <input value="3" id="group_1_inducedAbortion3_radio" name="group_1_inducedAbortion_radio" type="radio" class="" > <span class="text">2</span></label>
													<label class="col-lg-2"> <input value="4" id="group_1_inducedAbortion4_radio" name="group_1_inducedAbortion_radio" type="radio" class="" > <span class="text">3</span></label>
													<label class="col-lg-2"> <input value="5" id="group_1_inducedAbortion5_radio" name="group_1_inducedAbortion_radio" type="radio" class="" > <span class="text">>=4</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">19.您有过母乳喂养的经历吗？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"><input value="1" id="group_1_breastFeeding1_radio" name="group_1_breastFeeding_radio" type="radio" class="" > <span class="text">没有</span></label>
													<label class="col-lg-2"> <input value="2" id="group_1_breastFeeding2_radio" name="group_1_breastFeeding_radio" type="radio" class="" > <span class="text">有</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">20.您的月经是否规律？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"><input value="1" id="group_1_menstruationLaw1_radio" name="group_1_menstruationLaw_radio" type="radio" class="" > <span class="text">规律</span></label>
													<label class="col-lg-2"> <input value="2" id="group_1_menstruationLaw2_radio" name="group_1_menstruationLaw_radio" type="radio" class="" > <span class="text">不规律</span></label>
												</div>
											</div>
										</div>
										
										<div>
											<h4 class="block col-lg-12">21.您的月经量情况为？</h4>
											<div class="col-lg-12">
												<div class="form-group">
													<label class="col-lg-2"><input value="1" id="group_1_menstruationVolume1_radio" name="group_1_menstruationVolume_radio" type="radio" class="" > <span class="text">少</span></label>
													<label class="col-lg-2"> <input value="2" id="group_1_menstruationVolume2_radio" name="group_1_menstruationVolume_radio" type="radio" class="" > <span class="text">一般</span></label>
													<label class="col-lg-2"> <input value="3" id="group_1_menstruationVolume3_radio" name="group_1_menstruationVolume_radio" type="radio" class="" > <span class="text">多</span></label>
												</div>
											</div>
										</div>
										
										<div class="col-sm-8  col-xs-offset-3 btn-bottm" style="padding-top:25px">
											<button onclick="upData(0)" type="button" class="btn  btn-info col-sm-2 col-xs-offset-3">保存</button>
											<button onclick="history.go(-1);" type="button"  class="btn btn-active col-sm-2 col-xs-offset-3 next-btn">取消</button>
										</div>
									</div>
									</form>
							</section>
					<!--</div>-->
				</div>
			</div>
		</div>
		</div>
		</div>

	</body>
<script src="${ctx}/home/member/surveyRepor.js"></script>
<script type="text/javascript">
	var json = '${result}';
</script>
</html>


